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Showing results for "happened".

  1. psnet.ahrq.gov/web-mm/danger-disruption
    July 29, 2020 - Danger in Disruption Citation Text: Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  2. psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
    May 01, 2017 - Wrong Turn through Colon: Misplaced PEG Citation Text: Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote…
  3. psnet.ahrq.gov/web-mm/preventable-rash
    October 01, 2012 - Preventable Rash Citation Text: McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33622/psn-pdf
    November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP November 1, 2005 In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare I…
  5. psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
    February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. Citation Text: Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. …
  6. psnet.ahrq.gov/web-mm/missing-suction-tip
    January 01, 2006 - SPOTLIGHT CASE The Missing Suction Tip Citation Text: Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845472/psn-pdf
    March 15, 2023 - Colton Hood: That actually happened at the start of the COVID-19 public health emergency (PHE).
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49528/psn-pdf
    January 01, 2015 - The "Customer" Is Always Right February 1, 2007 Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/customer-always-right Case Objectives Understand the importance of identifying a patient's agenda. Appreciate the factors that contribute to unmet patient expectations. …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49633/psn-pdf
    September 01, 2011 - The Safety and Quality of Long Term Care September 1, 2011 Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care Case Objectives Identify commonly reported adverse events in long-term care. Identify two to three challenges…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33809/psn-pdf
    June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc June 1, 2016 In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc Editor's note: Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system tha…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838855/psn-pdf
    October 27, 2022 - False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022 Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose October 31, 2023 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/weight-and-…
  13. psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
    April 09, 2014 - SPOTLIGHT CASE The Hazards of Distraction: Ticking All the EHR Boxes Citation Text: Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49550/psn-pdf
    December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? December 1, 2007 Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals The Case …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33805/psn-pdf
    April 01, 2016 - In Conversation With… Thomas J. Nasca, MD, MACP April 1, 2016 In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp Editor's note: Dr. Nasca is Chief Executive Officer of the Accreditation Council for Graduate Medical Educat…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49408/psn-pdf
    July 01, 2003 - Check the Wristband July 1, 2003 Rosenthal M. Check the Wristband. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-wristband The Case The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the impending surgery. The patient spoke English and appeared to be of aver…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49602/psn-pdf
    April 01, 2010 - Anticoagulation: Held Too Long April 1, 2010 Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long The Case A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with abdominal pain. Because of the…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49660/psn-pdf
    August 01, 2012 - No News May Not Be Good News August 1, 2012 Moore CR. No News May Not Be Good News. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news Case Objectives Describe the frequency with which ambulatory test results are not followed up by providers. Appreciate that inadequate follow-up of…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33738/psn-pdf
    December 01, 2012 - In Conversation With... John G. Reiling, PhD December 1, 2012 In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with hospitals and…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60857/psn-pdf
    August 26, 2020 - Nothing Called Small Surgery August 26, 2020 Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery The Case  A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with progressive deformity of the …

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